The first accounts of a PIE

Here we explore the very first formulations of the PIE, in an article by Robin Johnson, a social worker turned researcher, & Rex Haigh, consultant psychiatrist and psychotherapist. Then its immediate adoption in the guidance published by the UK Dept of Communities and Local Government and the National Mental Health Development Unit.

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The term PIE was first proposed, in a paper on social policy and "the new social psychiatry" published in 2010 in the journal of Mental Health and Social Inclusion, where it was suggested as an apt description of the way that many homelessness services in the UK seemed to have been developing innovative ways to respond to the (often long-standing) mental health needs of their clientele. The authors, Johnson and Haigh each had extensive backgrounds in the therapeutic community approach in community mental health; and had both been instrumental in developing the UK Royal College of Psychiatrists' “enabling environments" programme.

Both were aware of the Dept of Health’s change of heart - as expressed in Personality Disorder; no longer a diagnosis of exclusion over the supposed untreatability of personality disorder – PD – and the need to find radically new ways of working, to meet the needs of this stigmatised and marginalised group (see for example: Recognising complexity). Both also knew the levels of poor mental health and of PD in the homelessness population; and of the creative work being done in some services to work with individuals whom the specialist mental health services struggled to engage as effectively.

They had been struck by the similarities between the more innovative services for this client group, and the earlier examples of therapeutic communities as they had developed after the World War II; and also by the similarities between these new ways of working, and the developments in innovative services for personality disorder, then being piloted by the Uk Dept of Health (with which Haigh himself was deeply involved).

For this kind of work in homelessness, they therefore suggested the phrase a ‘psychologically informed environment’, a PIE, to emphasise the way that, without claims to provide ‘therapy’’, these homelessness services seemed to be creating highly responsive but also quite holistic, integrated services, in, for example, hostels, refuges and youth foyers. It was, they argued, a whole environment that was created, and not simply a cluster of personalised services that happened to be in a building:

"Wherever any agency has effective control over many aspects of the day-to-day lives of the individuals living there, as for example in a hostel, a hospital or a prison, we have… a highly managed environment. When in addition the primary task or ethos of the service is the treatment, rehabilitation or other management of problematic behaviour, we therefore have an environment that is - or can be - to some degree consciously planned for the purpose, despite whatever inevitable practical constraints there may be.

The concept of a ‘psychologically informed environment’ then describes the outcome of an attempt to identify, adapt and consciously use those features of the managed environment in such a way as to allow the resources and the day-to-day functioning of the service to be focused on addressing the psychological needs and emotional issues thrown up by the residents. ……."

Whilst outlining this kind of work in their first article, Johnson & Haigh however explicitly avoided giving at that stage any more precise definition or specification of a PIE, suggesting only;

"As to how any service may approach the task, however, at this stage the field is entirely open. There is as yet, at least, no single or particular school of thought or of human understanding that necessarily underpins or informs the thinking in fostering a PIE. There is no one set of beliefs that the staff of a PIE need to sign up to, no overall view of the nature of human nature, or even of the underlying problems of the ‘membership’.

So it might be any form of psychological theory that might inform the work of the staff, from psychodynamics to behaviourism, from Gestalt to evolutionary psychology, Transactional Analysis, Dialectical Behavioural Therapy, Neuro-Linguistic Programming to existential humanism, and all points between and beyond. It is perhaps arguable that a meditation space or retreat founded on the more psychologically oriented faiths, such as Buddhism, might qualify. Certainly the York Retreat, that original template for compassionate care, has a good claim to the name.

But wherever that more psychological thinking can then be translated meaningfully into a carefully considered approach to re-designing and managing the social environment, then we have a PIE. It is these changes in day-to-day running, derived from reflective practice, that mark the development of the PIE.

But for the moment, at least, the definitive marker of a PIE is simply that, if asked why the unit is run in such and such a way, the staff would give an answer couched in terms of the emotional and psychological needs of the service users, rather than giving some more logistical or practical rationale, such as convenience, costs, or Health And Safety regulations.

Although training may well help, the key to psychological thinking here is not received wisdom, or even acquiring new skills, but reflective practice."

Johnson & Haigh had met and run workshops with the DCLG Rough Sleepers Team, and colleagues such as Nick Maguire at the University of Southampton; and Johnson went on to work with the DCLG team first, especially Helen Keats, on the PSA 16 programme. From these discussions arose the additional guidance that span off from that programme as an independent initiative, which eventually was published separately, as the “Non statutory guidance in meeting the psychological and emotional needs of people who are homeless”. (This document is now more commonly known as the ‘complex trauma guidance', as this was the abbreviated title it was given for publication on-line, by the National Mental Health Development Unit.)

This guidance paper argued that there were strikingly high levels of poor mental health in the homelessness and hostel population, and especially in entrenched ("chronic") homelessness; in many cases (estimated 60-70%) these problems were sufficient for a diagnosis of personality disorder. Nevertheless, the formulation of 'complex trauma' was preferable to that of personality disorder, both to avoid the stigma and 'therapeutic nihilism' associated with that term, and also to provide an account more consistent with contemporary recognition of the role of early trauma and subsequent re-traumatisation.

Finally, the guidance argued that the most effective homelessness services should be seen as frontline community mental health services working with mental health needs that the health service often did not cater for. This 'complex trauma guidance' then adopted the term PIE to describe the kind of holistic, robust yet responsive services that they saw as needed, to work with this challenging client group.

With the arrival of the Coalition government in 2010, the PSA 16 programme, which had originally brought Keats, Maguire and Johnson and others together, But being an independent initiative within the CLG team, this development was not closed down when the PSA 16 programme itself was disbanded; and instead, the idea was promptly taken up with some enthusiasm by services and local commissioners.

Thus the initial adoption of the term in the DCLG/NMHDU guidance then led to calls from within the homelessness sector for more guidance or advice on how to recognise, and/or how to develop, as a PIE. What had begun as a 'top down' government policy initiative was rapidly changing into something 'owned' by the homelessness sector itself.